Title: Quality of life in renal transplant recipients and the possibilities of its affecting through different forms of intervention. Aims: 1) To evaluate quality of life in renal transplant recipients and compare it with that of the general population. 2) To analyze effects of a 6 months controlled intervention exercise program, special diet, combination of special diet and exercise program and control group on the health related quality of life and to compare results between groups. Methods: We studied a composite group of 21 patients (mean age 58,4 9,34 years) after renal transplantation. Patients were randomly divided into four groups, each group had different program, as described above. The assessment of the quality of life was performed twice, before and after six months of a regular intervention program. We used standardized questionnaires KDQOL-SFTM . We have also assessed the importance of individual dimensions of quality of life with questionnaire WHOQOL - 100. Results were analyzed using descriptive statistics, non-parametric Wilcoxon signed-rank test and non-parametric Kruskal Wallis test. Statistically significance was considered on p ≤ 0,05. Results: After the pre-test and evaluation of the quality of life we assessed, that from 8 dimensions there were 5 lower after the...

INTRODUÇÃO: Os pacientes submetidos a transplante renal estão sujeitos a um risco muito aumentado para câncer, porém inexistem dados concretos quanto a maior chance de tumor de próstata nesses pacientes. Neste estudo, avaliou-se a freqüência de câncer de próstata em transplantados renais comparada à de pacientes-controle, bem como a sua relação com etnia, antecedentes familiares, toque prostático, níveis de PSA e aos esquemas de imunossupressão nos pacientes transplantados renais. MÉTODOS: Neste estudo caso-controle realizado entre agosto de 2004 e junho de 2006 comparou-se a freqüência de câncer de próstata entre pacientes transplantados renais (n=119) há mais de um ano e pacientes do grupo-controle (n=184), bem como as variáveis: etnia, idade, presença de antecedentes familiares, escore internacional de sintomas prostáticos, toque retal, níveis de PSA e índice de massa corpórea (IMC). Os pacientes com PSA e/ou toque retal alterado foram submetidos à biópsias prostáticas guiadas por ultra-som transretal. As comparações das freqüências entre os dois grupos deram-se através das variáveis: idade, etnia, presença de antecedentes familiares, toque suspeito e valores de PSA>2,5ng/mL e >4,0ng/mL. Avaliou-se também a relação entre os tipos e doses de imunossupressor e presença de câncer. RESULTADOS: Não houve maior freqüência de tumor de próstata em transplantados (6,7%) em relação ao grupo-controle (7,6%). A mediana de idade dos transplantados com câncer foi menor em relação aos controles (p=0,012). Os dois grupos não variaram quanto à etnia (p=0,675), ao peso (p=0,202), ao IMC (p=0,637) e à presença de antecedentes familiares (p=0,515) para detecção de tumor. O toque alterado não foi determinante para detectar tumor em ambos (p=0,659). Os pacientes transplantados apresentaram mediana de PSA menor que os controles (p=0,029). Com exceção da rapamicina, não houve associação entre o uso de imunossupressores e câncer (p>0,05) e as doses médias utilizadas em transplantados com e sem tumor não variaram de maneira estatisticamente significante (p>0,05). CONCLUSÕES: A freqüência de câncer de próstata em transplantados renais há mais de um ano assemelhase a da população de homens normais, é significativa quando se consideram valores de PSA entre 2,5ng/mL e 4,0ng/mL e não se relaciona com a dose e o tipo de droga imunossupressora / INTRODUCTION: Patients submitted to renal transplantation are at a greater risk to develop cancer, but there is no valuable data about prostate cancer in these patients. In this research we compared the frequencies of prostate cancer between renal transplanted recipients and control patients, as well as its relations with race, family history, digital rectal examination, PSA levels and the immunosupressive protocols applied to renal transplanted recipients. METHODS: In this case-control study performed between August 2004 and June 2006, we compared the frequency of prostate cancer between patients submitted to renal transplantation more than a year before the beginning of our study (n=119) and control patients (n=184), as well as its relations with race, age, international prostate symptoms score, digital rectal examination, PSA levels and body mass index (BMI). The patients who had high PSA levels and/or altered digital rectal examination were submitted to transrectal ultrasound guided biopsy of the prostate. The frequencies of cancer in both groups were compared by age, race, family history, altered digital rectal examination and PSA levels higher than 2,5ng/mL and 4,0ng/mL. The relationship between types and dosis of immunosupressive drugs and cancer were also analysed. RESULTS: The frequency of prostate cancer in renal transplanted patients (6,7%) was not higher than the frequency in control patients (7,6%). The median age of renal transplanted patients with cancer were lower when compared to control group with cancer (p=0,012). Race (p=0,657), body weight (p=0,202), BMI (p=0,637) and family history (p=0515) weren´t statistically different between both groups to detect cancer. Altered digital rectal examination wasn´t statistically significant to detect cancer in both groups (p=0,659). The median of PSA levels in renal transplanted recipients with cancer was lower when compared to control patients with cancer (p=0,029). There was no correlation between the use of immunosupressive drugs and occurrence of cancer (p>0,05), with exception of rapamycin. The median dosis of these drugs used in the group with cancer wasn´t statistically different from that used in transplanted patients without cancer (p > 0,05). Conclusions: The frequency of prostate cancer in patients submitted to renal transplantation more than a year before the study was the same as in control patients, it was significant when the PSA values were between 2,5ng/mL and 4,0ng/mL and it was not related to the type and dosis of immunosupressive drugs

Made available in DSpace on 2016-01-26T12:51:12Z (GMT). No. of bitstreams: 1 mariapaulaalvarenga_tese_parte 1.pdf: 552363 bytes, checksum: a74c19218fe01b85e1a7c0331018df0a (MD5) Previous issue date: 2006-12-15 / The chronic allograft nephropathy (CAN) accounts for approximately 60% of late renal allograft loss. High homocysteine level (Hcy) and genetic variability of renin-angiotensin system are the possibly risk factors. Objectives: To investigate the frequency of Angiotensin Conversion Enzyme (ACE I/D) gene deletion, and Metilenetetrahydrofolate reductase (MTHFR C677T and A1298C) variants, as well as to quantify the plasma homocysteine concentrations in 300 patients submitted to renal transplantation to evaluate these factors participation in CAN development. Furthermore the ingestion of micronutrients and the frequency of MTHFR T1317C polymorphism have been investigated. Material and Method: The molecular study was performed by polymerase chain reaction (PCR) and RFPL (Restriction fragment length polymorphism)techniques for polymorphism investigation. In accordance with clinical criteria established, the patients had been subdivided in patients with CAN and patients with normal renal function (NRF). The automatic sequencing was performed for MTHFR polymorphism A1298C confirmation and identification of MTHFR T1317C polymorphism. Plasma Hcy concentration was measured by liquid chromatography tandem mass spectrometry (LS-MS/MS) technique. Dietary intakes were evaluated by a validated dietary questionnaire. Results: There was no correlation between the ingestion of micronutrients and CAN. The 1317C polymorphism frequency was 7% in Brazilian recipients. The presence, at least, of one MTHFR (677T/1298C)variant was significantly more frequent in CAN (p=0.049; OR = 1.7; 95% IC: 1.0 3.1), and a higher risk for disease was observed in the presence of the polymorphic $&( (D) variant (677T/1298AC/ACED) (p=0.009; OR = 2.2; 95% IC: 1.2 4.2). The hyperhomocysteinemia was observed in 82.1% of the CAN group patients, and 68.2% from MRF group. and plasmatic medium values of Hcy have presented statistical significant difference between the groups (p=0.005 and p<0.0005, respectively). High medium level of Hcy were associated with 677TT genotype and 677TT1298AA combined genotype in CAN group (p=0.002 and p=0.018, respectively) and with the 1298A allele from NRF group (p=0.009). The individuals of NRF group with 1298AA genotype have presented higher medium levels than 1298AC (p=0.033) genotype, suggesting a protector factor for 1298A allele. In relation to the distribution of Hcy levels, the CAN group has presented greater number of patients classified with severe and intermediate yperhomocysteinemia (>30&#956;mol/L) (p=0.0005), in relation to NRF group. The 1298C allele presence, as well as the combination, at least, one 07+)5 (677T/1298C) polymorphic allele in patients with hyperhomocysteinemia, were more frequent in CAN group (p=0.007 and p=0.002). A risk for CAN was observed in this combination (MTHFR 677T/1298C) in hyperhomocysteinemia patients (OR = 2.8; 95% IC: 1.4 6.0). This risk is increased in the presence of the polymorphic $&( (D) variant (OR = 3.4; 95% IC: 1.5 8.1). This suggests that the combination of, at least, one polymorphic 07+)5 allele and ECA(in those patients with hyperhomocysteinemia can predispose recipients to CAN development. / A disfunção crônica do transplante (DCTx) constitui aproximadamente 60% das causas de perda do transplante. Entre os possíveis fatores envolvidos estão o aumento do nível da homocisteína (Hcy) no plasma e a variabilidade genética no sistema angiotensina renina. Objetivos: investigar as freqüências do polimorfismo de deleção do gene ECA (enzima conversora da angiotensina) e das variantes 677 e 1298 do gene MTHFR (metilenotetrahidrofolato redutase), bem como dosar a concentração plasmática de Hcy em pacientes submetidos a transplante renal, visando avaliar a participação destes fatores no desenvolvimento da DCTx. Também foram investigadas a ingestão de micronutrientes e a freqüência do polimorfismo MTHFR T13317C. Casuística e Métodos: Foram investigados 300 pacientes submetidos a transplante renal há no mínimo 12 meses. De acordo com critérios clínicos estabelecidos os pacientes foram subdivididos em pacientes com DCTx e pacientes com função renal normal (FN). O estudo molecular utilizou as técnicas de reação em cadeia da polimerase seguida de digestão enzimática para a investigação dos polimorfismos. O seqüenciamento automático foi realizado para confirmação do polimorfismo MTHFR A1298C e para identificação do polimorfismo MTHFR T1317C. A concentração plasmática de Hcy foi dosada por meio da técnica de cromatografia líquida/espectrometria de massas seqüencial. A ingestão de micronutrientes foi avaliada por meio de questionário validado cientificamente. Resultados: Não foi encontrada associação entre a ingestão de micronutrientes e a DCTx. A freqüência do polimorfismo 1317C foi de 7% na população de indivíduos transplantados brasileiros. A presença de pelo menos uma variante MTHFR (677T/1298C), foi significantemente mais freqüente em DCTx (p=0,049; OR = 1,7; 95% IC: 1,0 3,1) e um risco aumentado para doença foi observado na presença da variante polimórfica ECA (D) (677T/1298AC/ECAD) (p=0,009; OR = 2,2; 95% IC: 1,2 4,2). A hiper-homocisteinemia foi observada em 82,1% dos pacientes do grupo com DCTx e 68,2% do grupo de FN e os valores médios de Hcy plasmática apresentaram diferença estatisticamente significante entre os grupos (p=0,005 e p<0,0005, respectivamente). Nível médio elevado de Hcy foi associado com o genótipo 677TT e com o genótipo combinado 677TT/1298AA no grupo DCTx (p=0,002 e p=0,018, respectivamente) e ao alelo 1298A do grupo FN (p=0,009). Os indivíduos FN com o genótipo 1298AA apresentaram níveis médios mais elevados que àqueles com o genótipo 1298AC (p=0,033), sugerindo um fator protetor para o alelo 1298A. Em relação à distribuição dos níveis de Hcy, o grupo DCTx apresentou maior número de pacientes classificados com hiper-homocisteinemia intermediária e grave (>30&#956;mol/L) (p=0,0005), em relação ao grupo FN. A presença do alelo 1298C, bem como a combinação de pelo menos um alelo polimórfico MTHFR (677T/1298C) em pacientes com hiper-homocisteinemia foi mais freqüente no grupo DCTx (p=0,007 e p=0,002, respectivamente). Um risco para DCTx foi observado para essa combinação MTHFR 677T/1298C) (OR = 2,8; 95% IC: 1,4 6,0) e é aumentado na presença da variante polimórfica ECA (D) (OR = 3,4; 95% IC: 1,5 8,1). Conclusão: A combinação de pelo menos um alelo polimórfico MTHFR e ECA naqueles pacientes que apresentam hiper-homocisteinemia parece predispor o paciente transplantado a DCTx.

Submitted by Mariana Dornelles Vargas (marianadv) on 2015-05-12T20:57:43Z No. of bitstreams: 1 perfil_epidemiologico.pdf: 2713944 bytes, checksum: eef8d0d269396cdf4b5a233710b68003 (MD5) / Made available in DSpace on 2015-05-12T20:57:43Z (GMT). No. of bitstreams: 1 perfil_epidemiologico.pdf: 2713944 bytes, checksum: eef8d0d269396cdf4b5a233710b68003 (MD5) Previous issue date: 2009 / Nenhuma / Este estudo caracteriza o perfil epidemiológico e a qualidade de vida em crianças e adolescentes transplantados renais. É um estudo descritivo transversal, realizado com crianças e adolescentes na faixa etária de 5 a 18 anos de idade em acompanhamento no ambulatório de nefrologia do hospital da Criança Santo Antônio Porto-Alegre, RS. Os dados foram obtidos por dois instrumentos. Para caracterizar o perfil epidemiológico, foi utilizado um questionário que abordou informações sócio-demográficas e condições de saúde. Na avaliação da qualidade de vida, foi aplicado o Child Health Questionnaire-Parent Form 50 (CHQ-PF50). Para fins de comparação com uma população saudável, foram utilizados os dados publicados do estudo de validação do instrumento no Brasil. Comparando-se os resultados obtidos nas escalas do CHQ-PF50 com os dados obtidos em uma população de crianças saudáveis (grupo controle), percebeu-se que as diferenças nas médias dos escores foram menores em todas as escalas, exceto na escala referente à mudança no estado de saúde. Considera-se, para efeitos conclusivos, que a qualidade de vida relacionada à saúde em transplantados renais, a partir da percepção dos pais ou responsáveis, foi inferior àquela de crianças e adolescentes saudáveis da mesma faixa etária, especificamente no que tange os aspectos físicos e diretamente proporcionais ao nível sócio-econômico e escolaridade. / This study points the epidemiological profile and quality of life in children and adolescent renal transplant. It is a cross-sectional study conducted among children and adolescents aged 5 to 18 years old followed at the nephrology clinic of the hospital Santo Antônio, Porto Alegre, Brazil. Data were obtained by two instruments. To characterize the epidemiological profile, we used a questionnaire which addressed socio-demographic information and health conditions. When evaluating the quality of life, it was applied a Child Health Questionnaire-Parent Form 50 (CHQ-PF50). Due to comparing it to a healthy population it was used published data from the validation study's instrument in Brazil. Comparing the results obtained on the scales of the CHQ-PF50 with the data obtained in a population of healthy children (control group) it was perceived that the differences in average scores were lower on all scales except the scale concerning the change in health. It is conclusive for the present purpose, that quality of life related to health in kidney transplant patients from the perception of parents or guardians, was lower than that of healthy children and adolescents of the same age, specifically the terms and physical aspects directly proportional to socioeconomic status and educational level.

Submitted by Filipe dos Santos (fsantos@pucsp.br) on 2016-11-30T16:17:19Z No. of bitstreams: 1 Lucirley Mazera.pdf: 2529022 bytes, checksum: c9f0c26566b515ff8adf4d5ab601bcd1 (MD5) / Made available in DSpace on 2016-11-30T16:17:19Z (GMT). No. of bitstreams: 1 Lucirley Mazera.pdf: 2529022 bytes, checksum: c9f0c26566b515ff8adf4d5ab601bcd1 (MD5) Previous issue date: 2016-10-10 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Chronic kidney disease, hemodialysis and the possibility of kidney transplantation impose on people who are waiting for transplants, a large wear and a number of limitations involving biological, social, economic and psychological. In this context, the research aimed to analyze the guarantee of social rights to people waiting for kidney transplants from living and the most significant inflections that patients with chronic renal failure attributed to the disease, treatment and kidney transplantation. Through experience we have gathered in this area, with the stage that performed at the University of Barcelona and studies with this research, some aspects deserve our attention: the contribution of public health policies to chronic kidney as a guarantee of social rights, as DRC-154 2004 ANVISA; the related knowledge required to trigger social protection in Brazil highlighting the social security policies from the redesign of the 1988 Constitution; discriminatory process of segregation imposed by the disease; the importance of Social Services action with chronic renal failure on hemodialysis, through their professional action. Therefore, we decided to conduct a quantitative and qualitative research, overcoming prejudice to the numbers and learning to articulate them to the objective and subjective sphere the empirical data can provide. Because of this process were highlighted gaps in the communication process between health teams and users, and in particular the long trajectory of expectation that these patients are exposed. Around these issues have developed a reflection looking forward to the debate the essence of the profession / A doença renal crônica, o tratamento de hemodiálise e a possibilidade de cirurgia para transplante renal impõem às pessoas que estão em espera por transplante, um grande desgaste e uma série de limitações que envolvem o biológico, o social, o econômico e o psicológico. Neste contexto a pesquisa objetivou analisar a garantia dos direitos sociais às pessoas em espera por transplante renal a partir da vivência e das inflexões mais significativas que os portadores de insuficiência renal crônica atribuem à doença, ao tratamento e ao transplante renal. Através da experiência que reunimos nesta área, com o estágio que realizamos na Universidade de Barcelona e os estudos com a presente investigação, alguns aspectos mereceram nossa atenção: a contribuição das políticas públicas de saúde destinadas aos renais crônicos como garantia de direitos sociais, a partir da RDC-154 de 2004 da ANVISA; os conhecimentos correlatos necessários para acionar a proteção social no Brasil com destaque as políticas de Seguridade Social a partir da reformulação da Constituição de 1988; o processo discriminatório da segregação imposta pela doença; a importância da ação do Serviço Social com renais crônicos em hemodiálise, através de sua ação profissional. Para tanto, optamos por realizar uma pesquisa de natureza quantitativa e qualitativa, superando o preconceito para com os números e aprendendo a articulá-los às esferas objetivas e subjetivas que os dados empíricos podem oferecer. Como resultado deste processo ficaram evidenciadas lacunas no processo de comunicação entre equipes de saúde e seus usuários e em especial, a longa trajetória de expectativa a que ficam expostos estes doentes. Em torno destas questões desenvolvemos uma reflexão procurando remeter ao debate a essência da profissão

Le rejet d’allogreffe représente un obstacle majeur en transplantation rénale humaine. Le lymphocyte B (LB) joue un rôle lors de cette réaction contre le greffon, mal défini à ce jour. Notre objectif a été de caractériser et identifier son implication dans le rejet humoral chronique (cABMR) et le rejet cellulaire aigu (ACR). Dans une première partie, la caractérisation phénotypique des LB par cytométrie en flux chez ces patients a mis en évidence d’importantes différences dans la distribution des sous-populations de LB uniquement chez les patients cABMR. Chez les patients ACR, dont la distribution des LB n’est pas altérée, l’analyse de coupes de biopsies rénales a permis de mettre en évidence un infiltrat cellulaire constitué de lymphocytes B et T. Dans une seconde partie, l’activité fonctionnelle et régulatrice des LB issus de patients cABMR et ACR a été évaluée à l’aide d’un modèle in vitro de coculture entre des LB et des LT. Cette étude a révélé que les LB, issus des patients cABMR uniquement, sont dépourvus d’activités régulatrices sur la fonction des LT autologues. Cette étude a aussi mis en exergue que les LB des patients cABMR présentaient une déficience dans la sécrétion de molécules immunosuppressives telles que le TGFβ et l’indoleamine 2,3-dioxygénase (IDO). Ce défaut conduit à une incapacité à générer des lymphocytes T régulateurs. Finalement, notre étude a clairement démontré le rôle du LB dans les mécanismes physiopathologiques conduisant au rejet. Ces travaux ont donc permis de générer d’éventuelles perspectives pour définir de nouvelles stratégies thérapeutiques dans la lutte contre le rejet d’allogreffe. / Allograft rejection is one of the main obstacles in human kidney transplantation. The role of B lymphocytes in the response against the allograft is poorly understood. Our aim is to identify and clarify its involvement in chronical humoral and cellular rejection. First of all, we identify profound changes in the distribution of B lymphocytes in cABMR patients which was not the case for ACR patients. In those last ones, we were able to detect on kidney biopsies an important cellular infiltrate composed with B and T cells. In the second part of this work, the functional and regulatory functions of B cells from both groups of patients were analyzed by using an in vitro coculture model between B and T cells. It appeared that B lymphocytes isolated from cABMR patients were unable to inhibit autologous T cell activity. This study showed those cells failed to produce immunosuppressive molecules as TGFβ and indoleamine 2,3-dioxygenase (IDO) leading to a default in the generation of regulatory T cells. To conclude, this study clearly showed the roles of B cells in physiopathological mechanisms of allograft rejection and helped to define new therapeutical strategies to prevent or reduce its consequences for the patients.

In the present studies we have explored the link between food hypersensitivity and IgA nephropathy (IgAN) and evaluated treatment options in primary and recurrent disease. Approximately one third of our IgAN patients had a rectal mucosal sensitivity to gluten, as demonstrated by increased local mucosal nitric oxide production and/or myeloperoxidase release after gluten challenge. The gluten sensitivity seemed to be an innate immune reaction unrelated to the pathogenesis of celiac disease. Approximately half of the patients had a rectal mucosal sensitivity to soy or cow’s milk (CM). The levels of IgG antibodies to alfa-lactalbumin, beta-lactoglobulin and casein were significantly higher in CM sensitive as compared with non-sensitive IgAN patients, indicating that an adaptive immune response might be involved in addition to the innate immune reaction observed. With the knowledge of gastrointestinal reactivity enteric treatment was considered as a potential new treatment approach of IgAN. A 6-month prospective trial demonstrated proof-of-concept for the use of enteric budesonide targeted to the ileocaecal region of IgAN patients. We observed a modest, but significant reduction in urine albumin, a minor reduction of serum creatinine and a modest increase of eGFR calculated by the MDRD equation. eGFR calculated from the Cockcroft-Gault formula and cystatin C was not changed. In a retrospective study recurrence of IgAN and graft loss was evaluated in Norwegian and Swedish patients having received a primary renal transplant due to IgAN. Adjusting for relevant covariates, a multiple Cox-regression analysis on time to IgAN recurrence showed that use of statins was associated with reduced risk of recurrence and reduced risk of graft loss. The time lag from diagnosis to first transplantation and female gender were also associated with lower risk of recurrence. Improved graft survival was associated with related donor, low donor age and no or low number of acute rejection episodes.

Cytomegalovirus (CMV) is a β-herpesvirus that, after primary infection, establishes a life-long persistence in the human host. Up to 90% of humans are infected with CMV, that is kept under control by CMV-specific CD8+ and CD4+ T cells. In patients with an impaired cellular immunity, however, CMV infections can be life-threatening. Thus, it is vital to identify risk factors and target high-risk patients. In this thesis we have evaluated low-dose valacyclovir prophylaxis in renal transplant patients and studied CMV-specific T cell immunity in healthy and renal transplant patients. In renal transplant patients, the CMV serostatus of both the recipient (R) and the donor (D) has a major impact on the risk of developing CMV disease. In the high-risk D+/R- population, &gt;50% are likely to develop CMV disease in the absence of prophylaxis and/or pre-emptive therapy. We have used low-dose valacyclovir prophylaxis for high-risk renal transplant patients, and graft and patient survival up to 5 years after transplantation was comparable to data reported for other prophylactic protocols. The incidence of CMV disease and graft rejection during the first year after transplantation was also comparable to that achieved with other protocols, and without the adverse effects reported for other therapies. In the D+/R+ population, with a 15-35% risk of developing CMV disease, it is important to identify those individuals that are subject to a higher risk because of risk factors other than CMV serostatus. We therefore measured several immunologic parameters in renal transplant patients and in immunocompetent individuals with latent and primary CMV infection. In patients with a primary symptomatic CMV infection, CMV-specific CD8+ T cells peaked within a month after onset of symptoms but declined rapidly. In renal transplant patients, we found that the reduction in IFNγ-producing CMV-specific CD4+ T cells at 2 months post-transplantation may predict high-grade CMV DNAemia.

O estudo tem como objetivo geral avaliar a razão de custo-utilidade do tratamento da infecção pelo vírus da hepatite C (VHC) em pacientes dialisados, candidatos a transplante renal, tendo como esquemas terapêuticos alternativos o interferon-_ em monoterapia; o interferon peguilado em monoterapia; o interferon-_ em terapia combinada com ribavirina e o interferon peguilado em terapia combinada com ribavirina, comparando-os com o nãotratamento. A perspectiva do estudo foi a do Sistema Único de Saúde(SUS), que também serviu de base para estimar o impacto orçamentário da estratégia de tratamento mais custo efetiva. Para o alcance dos objetivos, foi construído um modelo de Makov para simulação de custos e resultados de cada estratégia avaliada. Para subsidiar o modelo, foi realizada uma revisão de literatura, a fim de definir os estados de saúde relacionados à infecção pelo vírus da hepatite C em transplantados e a probabilidade de transição entre os estados. Medidas de utilidade foram derivadas de consultas a especialistas. Os custos foram derivados da tabela de procedimentos do SUS. Os resultados do estudo demonstraram que o tratamento da infecção pelo VHC antes do transplante renal é mais custo-efetivo que o não tratamento, apontando o interferon-a como a melhor opção. O impacto orçamentário para adoção dessa estratégia pelo SUS corresponde a 0,3% do valor despendido pelo SUS com terapia renal substitutiva ao longo do ano de 2007. / The objective of the study was to analyze the cost-utility of the treatment of hepatitis C in patients on dialysis awaiting renal transplantation. The aim was to compare among distinct treatments: monotherapy with interferon-_, monotherapy with pegylated interferon, interferon-_ associated with ribavirin, and pegylated interferon with ribavirin, and with those without treatment. The perspective used was the Brazilian Public health system (SUS), which was also the base for calculating the costs of the treatment more cost effective. To analyze the data the Markov model was used for simulation of the costs and results obtained for each treatment used. Data from literature were used to define the health states of the transplanted patients infected by hepatitis C, and the probability of transition among the states. Utility measures derived from specialists evaluation. The costs derived from the procedures list of the SUS. The results show that treatment of hepatitis C before renal transplantation is more cost-effective compared with no treatment, and interferon-a is the best option. The budget impact of this strategy corresponds to 0.3% of the total amount used by the SUS with renal replacement therapy in the year of 2007.

Submitted by EMERSON DE ALBUQUERQUE SEIXAS null (emersondas@cardiol.br) on 2017-01-22T14:38:17Z No. of bitstreams: 1 Tese Doutorado apresentação final 17 Janeiro 2017 para repositório em PDF.pdf: 2272650 bytes, checksum: b1d116841eb237b23afc4bf970606f37 (MD5) / Approved for entry into archive by Juliano Benedito Ferreira (julianoferreira@reitoria.unesp.br) on 2017-01-25T16:50:55Z (GMT) No. of bitstreams: 1 seixas_ea_dr_bot.pdf: 2272650 bytes, checksum: b1d116841eb237b23afc4bf970606f37 (MD5) / Made available in DSpace on 2017-01-25T16:50:55Z (GMT). No. of bitstreams: 1 seixas_ea_dr_bot.pdf: 2272650 bytes, checksum: b1d116841eb237b23afc4bf970606f37 (MD5) Previous issue date: 2016-12-09 / Introdução: as doenças cardiovasculares representam a maior causa de mortalidade nos pacientes renais crônicos antes e após o transplante renal, dentre elas a doença coronariana apresenta destaque especial. Preditores de risco tem sido usados no seu diagnóstico que é desafiador. Poucos trabalhos validaram preditores clínicos de seleção para exames invasivos para o diagnóstico de doença arterial coronariana (DAC) antes do transplante renal. Objetivo: avaliar a frequência e poder discriminatório de preditores clínicos da presença da doença arterial coronariana em pacientes renais crônicos em programa de diálise candidatos ao transplante renal, avaliar a performance da fórmula de Gowdak e colaboradores de risco de doença arterial coronariana e verificar a associação entre doença arterial coronariana e desfechos no grupo estudado. Métodos: foram analisadas as cinecoronariografias de candidatos ao transplante renal de dois centros de transplante renal do estado de São Paulo, realizadas entre março de 2008 e abril de 2013. Foi realizado estudo transversal para verificar o poder preditivo de parâmetros clínicos para a presença de doença coronária significativa (estenose ≥70% em uma ou mais artérias epicárdicas ou ≥ 50% no tronco da coronária esquerda). Adicionalmente, verificou-se o poder discriminatório de um escore clínico de risco previamente estabelecido (que leva em conta presença de diabetes melito (DM), idade e manifestações clínicas de doença cardiovascular). Foi realizado também estudo longitudinal observacional e traçaram-se curvas de sobrevida de acordo com o diagnóstico angiográfico para verificar a associação entre a presença de doença coronária e desfechos. Resultados: foram rastreados 128 pacientes, dos quais, 23 foram excluídos. A prevalência de ateromatose coronária de qualquer grau foi de 60/105 (57%) e ateromatose coronária significativa foi de 30/105 (29%) no total da casuística. Os 105 pacientes restantes realizaram coronariografia, dois foram excluídos por falha de registro dos desfechos, portanto 103 foram incluídos em análise longitudinal. Dos 105 pacientes, em seis, a análise dos dados clínicos se mostrou incompleta. Estes foram excluídos do estudo transversal que foi realizado com 99 pacientes. Análise de regressão logística univariada identificou presença de DM, angina e/ou infarto prévio, clínica de doença arterial periférica e dislipidemia como preditores de DAC. Regressão logística múltipla identificou apenas diabetes e angina e/ou infarto prévio como preditores independentes. O escore clínico previamente desenvolvido apresentou associação estreita com o diagnóstico de DAC, o que valida seu uso nos pacientes estudados. A mortalidade foi menor do que à esperada entre os pacientes em diálise. A presença de DAC foi associada à ocorrência de eventos cardiovasculares, porém não se associou à mortalidade. Conclusão: a DAC foi frequente em pacientes renais crônicos em programa de diálise candidatos ao transplante renal, pode ser identificada por dados clínicos e sua identificação por angiografia pode prever evento cardiovascular. / Introduction: cardiovascular diseases are major causes of mortality in chronic renal failure patients before and after renal transplantation. Among them, coronary disease presents a special emphasis. Predictors of risk for coronary artery disease has been used for its diagnosis. Few studies have validated clinical predictors to selection patients for invasive procedures for the diagnosis of coronary artery disease (CAD) before renal transplantation. Objective: this study evaluated the frequency and discriminatory power of clinical predictors of coronary artery disease in chronic renal failure patients undergoing dialysis who were renal transplant candidates, assessed a previously developed scoring system (Gowdak et al.) for coronary artery disease, and we also checked the association between coronary artery disease and outcomes of the study group. Methods: coronary angiographies conducted between March 2008 and April 2013 from candidates for renal transplantation from two transplant centers in São Paulo state were analyzed. Cross-sectional study was conducted to verify the predictive power of clinical parameters for the presence of significant coronary artery disease (≥70% stenosis in one or more epicardial artery or ≥ 50% in the left main coronary artery). In addition, the discriminating power of a previously established clinical risk score was assessed (which takes account of diabetes mellitus (DM), age and clinical manifestations of cardiovascular disease). It was also conducted observational longitudinal study and drew up survival curves according to the angiographic diagnosis to verify the association between the presence of coronary heart disease and outcomes. Results: we screened 128 patients, of which 23 were excluded. The prevalence of coronary atheromatosis of any grade was 60/105 (57%) and significant coronary atheromatosis was 30/105 (29%) in the total sample. The remaining 105 patients underwent coronary angiography, two were excluded because of recording outcomes failures, so 103 were included in the longitudinal analysis. Of the 105 patients, in six, the analysis of clinical data showed incomplete. These were excluded from the cross-sectional study that was conducted with 99 patients. Univariate logistic regression analysis identified the presence of DM, angina and / or previous infarction, clinical peripheral artery disease and hyperlipidemia as predictors of CAD. Multiple logistic regression identified only diabetes and angina and / or previous infarction as independent predictors. The previously developed scoring system showed a close association with the diagnosis of CAD, which validates its use in the patients studied. Mortality was lower than expected among patients on dialysis. The presence of CAD was associated with cardiovascular events and was not a predictor of mortality. Conclusion: the CAD was frequent in renal failure patients on dialysis candidates to kidney transplantation, can be identified by clinical data and identification by angiography can predict cardiovascular events.